Compositions and methods for treating pterygium

ABSTRACT

Compositions and methods for inducing pterygium regression from visual axis/central cornea, stabilizing pterygium, treating hyperemia and symptoms in pterygium patients, and treating pterygium recurrence following pterygiectomy are disclosed. The methods include administration of a multikinase inhibitor, an antimetabolite or a combination thereof to patients in need thereof.

CLAIM OF PRIORITY

This application is a continuation of U.S. patent application Ser. No.15/375,820, filed on Dec. 12, 2016, which is a continuation ofInternational Application No. PCT/US2016/035726, filed on Jun. 3, 2016,which claims the benefit of U.S. Provisional Patent Application Ser. No.62/172,063, filed on Jun. 6, 2015 and U.S. Provisional PatentApplication Ser. No. 62/186,660, filed on Jun. 30, 2015, the entirecontents of each are hereby incorporated by reference.

TECHNICAL FIELD

The present disclosure relates to ocular compositions and methods fortreating primary and recurrent pterygium, and more particularly tocompositions and methods for inducing pterygium regression from visualaxis/central cornea, stabilize pterygium, reducing ocular hyperemia andpterygium recurrence prior to, in conjunction with or followingpterygium surgery.

BACKGROUND

Pterygium is an ocular surface disease, where an abnormal epithelial andfibroblast growth extends from the nasal or temporal conjunctiva acrossthe limbus onto the cornea. Pterygium patients often experience symptomsof ocular discomfort, hyperemia, and are at risk of visual impairment ifthe lesion encroaches on the visual axis.

SUMMARY

In certain aspects, the disclosure provides a method for treatingprimary and recurrent pterygium by administering (1) a multikinaseinhibitor, (2) an antimetabolite or (3) a combination of a multikinaseinhibitor and an antimetabolite to the eye of a subject in need of suchtreatment. In certain aspect, the disclosed methods stabilize pterygiumand prevent further growth of the diseased tissue. In another aspect,the disclosed methods induce pterygium regression from visualaxis/central cornea. In certain aspect, the disclosed multikinaseinhibitor targets kinase receptors of VEGFR (1, 2, 3) and PDGFR (α, β).In certain aspect, the multikinase inhibitor is in a topical ocularformulation administered topically to the affected eye. In certainaspect, the topical ocular formulation is a solution, a suspension or anemulsion. In another aspect, the multikinase inhibitor is in an implantor semi-solid sustained release formulation injected into the affectedeye. In certain aspect, the antimetabolites are Mitomycin C,5-Fluorouracil and Thiotepa. In certain aspect, the antimetabolite is ina topical ocular formulation administered topically to the affected eye.In certain aspect, the topical ocular formulation is a solution, asuspension or an emulsion. In another aspect, the antimetabolite is inan implant or semi-solid sustained release formulation injected into theaffected eye. In certain aspect, the disclosed methods are performed bythe combination of a multikinase inhibitor and an antimetabolite. Incertain aspect, the combination of a multikinase inhibitor and anantimetabolite is in a topical ocular formulation administered topicallyto the affected eye. In certain aspect, the topical ocular formulationis a solution, a suspension or an emulsion. In another aspect, thecombination of a multikinase inhibitor and an antimetabolite is in animplant or semi-solid sustained release formulation injected into theaffected eye. In certain aspect, the disclosed methods reduce hyperemia,abnormal neovascularization and other symptoms in pterygium patients. Inanother aspect, the disclosed methods prevent pterygium recurrencefollowing pterygium surgery. In certain aspect, the disclosed methodsare performed before surgical removal of pterygium, in conjunction withsurgery for pterygium removal or after surgical removal of pterygium, toreduce or prevent pterygium recurrence. In certain aspect, the disclosedmultikinase inhibitor targets minimum kinase receptors of VEGFR (1, 2,3), PDGFR (α, β), FGFR (1, 2, 3, 4) and optimal kinase receptors ofFLT3, Lck, Lyn and Src as additional. In certain aspect, the disclosedmultikinase inhibitor is nintedanib. In certain aspect, the disclosedmethods use a topical ocular formulation. In certain aspect, theformulation is an aqueous solution, a suspension or an emulsion. Incertain aspect, the concentration of nintedanib in the formulation isfrom 0.001% to 10%. In certain aspect, the formulation is an implant orsemi-solid sustained release formulation injected into the affected eye.In certain aspect, the amount of nintedanib in the implant is from 1 μgto 100 mg.

In one aspect, the disclosure provides for a method for inducingpterygium regression from visual axis/central cornea, includingadministering to an affected eye of a subject in need of such treatmenta therapeutically effective amount of (1) a multikinase inhibitor; (2)an antimetabolite that blocks epithelial and fibroblast cellproliferation; or (3) a combination thereof. In some embodiments of allaspects, the administration of the multikinase inhibitor, theantimetabolite, or combination thereof results in a decrease of thepterygium size in the affected eye. In some instances, theadministration of the multikinase inhibitor, the antimetabolite, orcombination thereof results in a negative pterygium growth rate in theaffected eye.

In another aspect, the disclosure provides for a method for stabilizingpterygium, including administering to an affected eye of a subject inneed of such treatment a therapeutically effective amount of (1) amultikinase inhibitor; (2) an antimetabolite that blocks epithelial andfibroblast cell proliferation; or (3) a combination thereof. In somecases, the administration of the multikinase inhibitor, theantimetabolite, or combination thereof results in stabilization of thepterygium size in the affected eye. In some instances, theadministration of the multikinase inhibitor, the antimetabolite, orcombination thereof results in an about zero pterygium growth rate inthe affected eye.

In some embodiments of all aspects, the multikinase inhibitor reducesthe activity of one or more intracellular and/or cell surface proteinkinases selected from EGFR, ErbB2, ErbB3, FGFR1, FGFR2, FGFR3, FGFR4,TrkA, NGFR, VEGFR (1, 2, 3), PDGFR (α, β), TGF-βR (I, II, III), FLT3,Lck, Lyn, Src, c-Kit, c-Fms, Raf-1, B-Raf, RET, CSF-1R) in pterygium. Insome cases the multikinase inhibitor has an IC50 against VEGFR (1, 2, 3)of <200 nM, an IC50 against PDGFR (α, β) of <200 nM, and/or an IC50against FGFR (1, 2, 3) of <1000 nM.

In some embodiments of all aspects, the multikinase inhibitor isselected from the group consisting of Afatinib, Amuvatinib, Axitinib,Cabozantinib, Canertinib, Cediranib, Ceritinib, Crenolanib, Crizotinib,Dabrafenib, Dacomitinib, Dasatinib, Erlotinib, Foretinib, Gefitinib,Golvatinib, Ibrutinib, Icotinib, Idelalisib, Imatinib, Lapatinib,Lenvatinib, Neratinib, Nilotinib, Nintedanib, Palbociclib, Pazopanib,Ponatinib, Quizartinib, Regorafenib, Ruxolitinib, Sorafenib, Sunitinib,Tandutinib, Tivantinib, Tivozanib, Trametinib, Vandetanib, Vatalanib,and Vemurafenib. In some cases, the antimetabolite is selected from thegroup consisting of Mitomycin C, 5-Fluorouracil, Floxuridine,Cytarabine, 6-azauracil, Azathioprine, Methotrexate, MycophenolateMofetil, and Thiotepa.

In some embodiments of all aspects, the multikinase inhibitor, theantimetabolite, or combination thereof is administered to the affectedeye in the form of topical ocular formulation, an ointment, a gel, asustained release semi-solid formulation, a sustained release solidformulation or ocular implant. In some cases, the multikinase inhibitor,the antimetabolite, or combination thereof is administered to theaffected eye in the form topical ocular formulation and is administeredtopically to the affected eye.

In some instances, the topical ocular formulation is a solution, asuspension or an emulsion. In some cases, the topical ocular formulationalso includes one or more pharmaceutically acceptable excipientsselected from stabilizers, surfactants, polymer base carriers, gellingagents, organic co-solvents, pH active components, osmotic activecomponents and with or without preservatives. In some cases, thesustained release semi-solid formulation, sustained release solidformulation or ocular implant is injected into the affected eye. In someembodiments, the sustained release semi-solid formulation, sustainedrelease solid formulation or ocular implant further comprises apharmaceutically acceptable excipient. In some cases, the sustainedrelease semi-solid formulation, sustained release solid formulation orocular implant includes a multikinase inhibitor, the antimetabolite, orcombination thereof; and a biodegradable polymer selected frompolylactic acid (PLA), polyglycolic acid (PLGA) and polylactic acidpolyglycolic acid copolymers.

In some embodiments of all aspects, the administration is performed onpterygium patients.

In another aspect, the disclosure provides for a method for reducinghyperemia and symptoms thereof in in the pterygium, pinguecula andpseudopterygium of a patient in need of such treatment, includingadministering to an affected eye of the subject a therapeuticallyeffective amount of a multikinase inhibitor.

In another aspect, the disclosure provides for a method for reducing orpreventing pterygium recurrence in a subject in need of such treatmentincluding administering to an affected eye of the subject atherapeutically effective amount of a multikinase inhibitor. In someembodiments of all aspects, the administration is performed prior tosurgical removal of pterygium. In some instances, the administration isperformed during a surgical procedure to removal of pterygium. In somecases, the administration is performed following surgical removal ofpterygium.

In some embodiments of all aspects, the multikinase inhibitor has anIC50 against VEGFR (1, 2, 3) of <50 nM, an IC50 against PDGFR (α, β) of<100 nM, an IC50 against FGFR (1, 2, 3) of <150 nM, an IC50 againstFGFR4 of <1000 nM, an IC50 against FLT3 of <50 nM, an IC50 against Lckof <50 nM, an IC50 against Lyn of <200 nM), and an IC50 against Src of<200 nM. In some cases, the multikinase inhibitor is selected from thegroup consisting of nintedanib {Methyl(3Z)-3-{[(4-{methyl[(4-methylpiperazin-1-yl)acetyl]amino}phenyl)amino](phenyl)methylidene}-2-oxo-2,3-dihydro-1H-indole-6-carboxylate}, thefree base, a hydrate, solvate or pharmaceutically acceptable salt ofthereof. In some instances, the multikinase inhibitor is nintedanib freebase or nintedanib esylate (ethanesulfonate salt).

In some embodiments of all aspects, the multikinase inhibitor isadministered to the affected eye in the form of topical ocularformulation, a sustained release semi-solid formulation, a sustainedrelease solid formulation or ocular implant. In some cases, nintedanibis administered to the affected eye in the form topical ocularformulation and is administered topically to the affected eye. In somecases, the topical ocular formulation is a solution, a suspension or anemulsion. In some embodiments of all aspects, the concentration ofnintedanib in the topical ocular formulation is from 0.001% to 10% byweight of the total amount of the formulation.

In some embodiments of all aspects, the topical ocular formulation alsoincludes one or more pharmaceutically acceptable excipients selectedfrom stabilizers, surfactants, polymer base carriers, gelling agents,organic co-solvents, pH active components, osmotic active components andpreservatives. In some cases, the sustained release semi-solidformulation, sustained release solid formulation or ocular implant isinjected into the affected eye. In some instances, the sustained releasesemi-solid formulation, sustained release solid formulation or ocularimplant includes nintedanib and a pharmaceutically acceptable excipient.In some cases, the amount of nintedanib in the sustained releasesemi-solid formulation, sustained release solid formulation or ocularimplant is 1 μg to 100 mg. In some instances the sustained releasesemi-solid formulation, sustained release solid formulation or ocularimplant comprises nintedanib; and a biodegradable polymers selected frompolylactic acid (PLA), polyglycolic acid (PLGA) and a polylactic acidpolyglycolic acid copolymer.

As used herein, the term “one or more” includes at least one, moresuitably, one, two, three, four, five, ten, twenty, fifty, one-hundred,five-hundred, etc., of the item to which “one or more” refers.

The term “subject” refers to an animal or human, or to one or more cellsderived from an animal or human. Preferably, the subject is a human.Subjects can also include non-human primates. A human subject can beknown as a patient.

Unless otherwise defined, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Methods and materials aredescribed herein for use in the present invention; other, suitablemethods and materials known in the art can also be used. The materials,methods, and examples are illustrative only and not intended to belimiting. All publications, patent applications, patents, sequences,database entries, and other references mentioned herein are incorporatedby reference in their entirety. In case of conflict, the presentspecification, including definitions, will control.

Other features and advantages of the invention will be apparent from thefollowing detailed description and figures, and from the claims.

DESCRIPTION OF DRAWINGS

The patent or application file contains at least one drawing executed incolor. Copies of this patent or patent application publication withcolor drawing(s) will be provided by the Office upon request and paymentof the necessary fee.

FIGS. 1A and 1B are graphs demonstrating the anti-vascularizationefficacies of nintedanib in a rabbit cornea suture model. FIG. 1Aprovides results on day 12 and FIG. 1B provides results on day 14. Thearea of cornea neovascularization are shown for each treatment groups.Group 1: positive control sunitinib 0.05% TID; group 2: 0.2% nintedanibBID; group 3: 0.2% nintedanib TID; group 4: 0.05% nintedanib BID; group5: 0.05% nintedanib TID; group 6: vehicle control TID. T-testsignificance levels comparing each group vs vehicle are shown byasterisk symbols.

FIGS. 2A and 2B are graphs demonstrating the effects of nintedanib(CBT-001) in the human pterygium mouse model. (2A) 0.2% nintedanibreduced pterygium lesion area on mouse cornea. The pterygium lesion areaon day 14 and day 17 are significantly smaller than the baseline levelon day 7. In contrast, the pterygium area in the saline control eyesincreased over the 10-day period with day 14 and 17 significantly morethan day 7. (2B) 0.2% nintedanib reduced the neovascularization oncornea and the reduction was significant comparing levels on day 17 vsthe baseline on day 7. In the saline control eye, the neovascularizationslightly increased without statistically significant difference frombaseline.

FIGS. 3A and 3B are graphs demonstrating the effects of sunitinib(CBT-003) in the pterygium mouse model. (3A) 0.05% sunitinib showed atrend of reduction of pterygium lesion area but the differences at eachtime points from the day 7 baseline are not statistically significant.The pterygium area in the saline control eyes increased over the 10-dayperiod with day 14 and 17 significantly more than day 7. (3B) 0.05%sunitinib reduced the neovascularization on cornea and the reduction wassignificant comparing levels on day 14 and 17 vs the baseline on day 7.In the saline control eyes, the neovascularization did not changesignificantly.

FIGS. 4A and 4B are graphs demonstrating the effects of mitomycin(CBT-002) in the pterygium mouse model. (4A) 0.002% mitomycin showed atrend of reduction of pterygium lesion area but the differences at eachtime points from the day 7 baseline are not statistically significant.The pterygium area in the saline control eyes increased with day 10, 14and 17 significantly more than day 7. (4B) 0.002% mitomycin reduced theneovascularization on cornea and the reduction was significant comparinglevels on day 17 vs the baseline on day 7. In the saline control eyes,the neovascularization did not change significantly.

FIGS. 5A and 5B are graphs demonstrating the effects of combination ofnintedanib (CBT-001) and mitomycin (CBT-002) in the pterygium mousemodel. (5A) the pterygium area in the saline control eyes increased withday 14 and 17 significantly more than day 7 while the area didn'tsignificantly increase in the combo treatment group. (5B) theneovascularization area did not change significantly in saline and combotreatment groups.

DETAILED DESCRIPTION

Pterygium is an ocular surface disease, where a fibrovascular growthextends from the nasal or temporal conjunctiva across the limbus ontothe cornea. Pterygium patients often experience symptoms of oculardiscomfort, hyperemia, and are at risk of visual impairment if thelesion encroaches on the visual axis. The incidence of pterygium ispositively associated with lifetime sun exposure and other risk factorssuch as increasing age, male gender, and rural residency, whilst wearingglasses or a hat has been shown to have a protective effect. Inaddition, pterygia are more common in some occupational groups, such aswelders, laborers, and those that work outdoors, which reflects a keyrole of ultraviolet (UV) exposure in the pathogenesis of this disease.

Pterygia are often considered as benign tumors due to their invasivegrowth habit and propensity for recurrence, but not metastasis. Thecurrent understanding of the pathogenesis of pterygium is that multipleprocesses are involved and these may be divided into inherited factors,environmental triggers (UV light, viral infections), and factors thatperpetuate its growth (cytokines, growth factors and matrixmetalloproteinases). Among them, chronic UV exposure is the single mostsignificant factor in the pathogenesis of pterygium. The relationshipbetween UV exposure and pterygia is well supported by epidemiologicalstudies and its association with other UV-related conditions such asphotoaged skin, cataracts, climatic droplet keratopathy, and squamouscell and basal cell carcinomas. UV-activated molecular mechanisms, suchas oxidative stress and growth factor receptor (GFR) signaling, lead tothe synthesis and secretion of effector molecules such as cytokines,growth factors and matrix metalloproteinases that perpetuate the growthof the pterygia. UV is a well-known inducer of oxidative stress and acontributor to cutaneous photoaging. Oxidative stress, triggered by UV,mediates activation of epidermal growth factor receptors (EGFRs) andsubsequent downstream signaling via the mitogen-activated protein kinasepathways.

Currently, there is no approved pharmacologic therapy to treat pterygia.Pterygium excision with conjunctival autograft transplantation remainsthe procedure of choice for definitive treatment of both primary andrecurrent pterygia. While many of these lesions can be readily removedto the initial satisfaction of both surgeon and patient, the recurrenceof pterygium could occur. Antimetabolites, such as 5-FU, and MIVIC havebeen used in conjunction with or after pterygium surgery to decrease therecurrence rate of pterygia (Almond et al., Pterygium: Techniques andTechnologies for Surgical Success. Hovanesian J A. Ed. SLACKIncorporated. 2012; pp 55-63).

Pterygium is a multifactorial disease and several growth factors such asVEGF and PDGF are potential pathological factors. However, no drugagainst these growth factors has been developed to treat the disease.The anti-VEGF antibodies bevacizumab and ranibizumab have been tested inpterygium patients in the clinic around the world but the results arehighly variable and it is not clear whether such treatment usingantibodies are effective. A few studies reported that bevacizumab couldstop pterygium growth but most of studies reported negative results. Todate, there have been no reports of a small molecule anti-angiogenesisdrug being tested in the clinic for pterygium. The human pterygium mousemodel was developed recently with only two publications (Lee et al.Graefes Arch Clin Exp Ophthalmol. 2014; 252(4):609-18; Cox et al.Ophthalmology. 2010; 117(9): 1782-91). No anti-angiogenesis drugs haveever been tested in this model before. Provided below, for the firsttime, the inventors demonstrate that multikinase inhibitors withanti-angiogenesis activities effectively inhibit and/or stabilizepterygium growth and reduce pterygium tissue lesion size in the mousemodel. In addition, the inventors demonstrate that antimetaboliteprovide analogous results. The present disclosure is based, in part, onthese novel findings. Thus, the present disclosure provides compositionsand methods of administering a multikinase inhibitor, an antimetabolite,or a combination of a multikinase inhibitor with an antimetabolite totreat pterygium by stabilizing the disease and inducing regression.

As used herein, the term “pterygium regression” means a decrease orreduction of the pterygium size in an affected eye. For example, theterm “pterygium regression” means a decrease or reduction of thepterygium size in an affected eye by at least 5%, at least 10%, at least15%, at least 20%, at least 25%, at least 30%, at least 35%, at least40%, at least 45%, at least 50%, at least 55%, at least 60%, at least65%, at least 70%, at least 75%, at least 80%, at least 85%, at least90%, at least 95%, or at least 100%.

As used herein, the term “ocular hyperemia” or “hyperemia” refers toredness in an eye resulting from an excess of blood in the white of theeyes (sclera). The term “reducing hyperemia” means be reduction inredness and\or increase in whiteness in an affected eye. The reductionin redness and\or increase in whiteness can be confirmed or measured bymethods well known to those skilled in the art, including visualassessment by a professional.

As used herein, the term “stabilizing pterygium” or “stabilization ofthe pterygium size” refers to means maintaining pterygium size in anaffected eye.

As used herein, the term “pterygium recurrence” means the reappearanceof pterygium in an eye following removal (e.g., surgical removal) ofprimary pterygium.

As used herein, the terms “therapeutically effective” and “effectiveamount” refer to that amount of an agent effective to produce theintended pharmacological, therapeutic or preventive result. Thepharmacologically effective amount results in the amelioration of one ormore symptoms of a disorder, or prevents the advancement of a disorder,or causes the regression of the disorder, or prevents the disorder. Forexample, with respect to inducing pterygium regression, atherapeutically effective amount refers to the amount of a therapeuticagent that reduces pterygium size, by at least 5%, at least 10%, atleast 15%, at least 20%, at least 25%, at least 30%, at least 35%, atleast 40%, at least 45%, at least 50%, at least 55%, at least 60%, atleast 65%, at least 70%, at least 75%, at least 80%, at least 85%, atleast 90%, at least 95%, or at least 100%.

Therapeutically effective dosages in the methods described herein can bedetermined by the treating physician. For example, the physician maybegin treatment using manufacturer-recommended doses for the multikinaseinhibitor or antimetabolite, and make adjustments based on thephysician's observations of the effect of treatment. Further guidance isprovided herein and in the Examples. In addition, clinical trials can beconducted to determine the doses that are effective to producestatistically significant treatment effects when a population ofpatients is treated.

The phrase “or combination thereof” or “in combination with” is intendedto refer to all forms of administration that provide a first agenttogether with a second agent, such as a second inhibitory nucleic acidmolecule or a chemotherapeutic agent, where the two are administeredconcurrently or sequentially in any order. For two or more agents to beadministered in combination with each other, the agents need not beadministered simultaneously or in the same formulation. Agentsadministered in combination with each other simultaneously present orhave biological activity in the subject to which the agents aredelivered. Determination of the presence of an agent in a subject can bereadily determined by empirical monitoring or by calculations usingknown pharmacokinetic properties of the agents.

The terms “treatment”, “treating”, “treat” and the like are used hereinto generally refer to obtaining a desired pharmacologic and/orphysiologic effect. The effect can be prophylactic in terms ofcompletely or partially preventing a disease or symptom(s) thereofand/or may be therapeutic in terms of a partial or completestabilization or cure for a disease and/or adverse effect attributableto the disease. The term “treatment” encompasses any treatment of adisease in a mammal, particularly a human, and includes: (a) preventingthe disease and/or symptom(s) from occurring in a subject who may bepredisposed to the disease or symptom but has not yet been diagnosed ashaving it; (b) inhibiting the disease and/or symptom(s), i.e., arrestingtheir development; or (c) relieving the disease symptom(s), i.e.,causing regression of the disease and/or symptom(s). Those in need oftreatment include those already inflicted (e.g., those with cancer,those with an infection, etc.) as well as those in which prevention isdesired (e.g., those with increased susceptibility to cancer, those withan increased likelihood of infection, those suspected of having cancer,those suspected of harboring an infection, etc.).

As used herein, the term “multikinase inhibitor” (MKI) refers to drugcompounds (e.g., a small molecule) that reduce or inhibit the expressionor activity of two or more kinases, including, for example,intracellular and/or cell surface protein kinases.

As used herein, “small molecule” is understood to refer to a chemicalcompound having a molecular weight below 2,000 daltons, more preferablybetween 200 and 1,000 daltons, and still more preferably between 300 and700 daltons. It is preferred that these small molecules are organicmolecules. In certain embodiments, “small molecule” does not includepeptide or nucleic acid molecules.

Exemplary multikinase inhibitors for use in the methods described hereindemonstrate certain kinase inhibition profiles. For example, multikinaseinhibitors for use in the methods described herein can have a kinaseinhibition profile with an IC50 against VEGFR (1, 2, 3) of IC₅₀<200 nM,PDGFR (α, β) of IC₅₀<200 nM, and FGFR (1, 2, 3) of IC₅₀<1 μM.

Exemplary multikinase inhibitors for use in the methods described hereininclude, for example, Afatinib, Amuvatinib, Axitinib, Cabozantinib,Canertinib, Cediranib, Ceritinib, Crenolanib, Crizotinib, Dabrafenib,Dacomitinib, Dasatinib, Erlotinib, Foretinib, Gefitinib, Golvatinib,Ibrutinib, Icotinib, Idelalisib, Imatinib, Lapatinib, Lenvatinib,Neratinib, Nilotinib, Nintedanib, Palbociclib, Pazopanib, Ponatinib,Quizartinib, Regorafenib, Ruxolitinib, Sorafenib, Sunitinib, Tandutinib,Tivantinib, Tivozanib, Trametinib, Vandetanib, Vatalanib, andVemurafenib.

Nintedanib {Methyl(3Z)-3-{[(4-{methyl[(4-methylpiperazin-1-yl)acetyl]amino}phenyl)amino](phenyl)methylidene}-2-oxo-2,3-dihydro-1H-indole-6-carboxylate} is anexample of a multikinase inhibitor as described herein. Nintedanibinhibits primarily receptor tyrosine kinases including, for examplevascular endothelial growth factor receptor (VEGFR 1-3),platelet-derived growth factor receptor (PDGFR α and β), fibroblastgrowth factor receptor (FGFR 1-4) and others (see Table 1 below) anddisplays unique kinase inhibition profile.

TABLE 1 Kinase targets IC₅₀ (nM) Nintedanib Sunitinib VandetanibSorafenib Pazopanib Vatalanib VEGFR1 34 21 9 7 77 VEGFR2 21 34 40 28 1537 VEGFR3 13 3 7 2 660 PDGFRα 59 143 933 73 PDGFRβ 65 75 1129 215 580FGFR1 69 437 64 80 FGFR2 37 852 350 FGFR3 108 314 138 FGFR4 610 FLT3 264 45 619 LCK 16 95 379 Lyn 195 Src 156 c-Kit 40 1862 48 730 c-Fms 5 6Raf-1 6 B-Raf 22 RET 232 ? CSF-1R EGFR ? Axitinib Cediranib RegorafenibTivozanib Motesanib Linifanib VEGFR1 0.1 5 13 30 2 3 VEGFR2 0.2 0.5 4.26.5 3 4 VEGFR3 0.2 3 46 15 6 190 PDGFRα 5 36 40 84 PDGFRβ 1.6 5 22 49 66FGFR1 26 202 530 FGFR2 FGFR3 FGFR4 FLT3 4 LCK Lyn Src 130 960 c-Kit 1.77 78 8 14 c-Fms Raf-1 2.5 B-Raf 19 RET 59 CSF-1R 73 110 3 EGFRNintedanib data from Hilberg et al, Cancer Res 2008; 68: (12),4774-4782. Sunitinib, sorafenib and pazopanib data from British Journalof Cancer 2009; 101, 1717-1723. Other data from selleckchem database.For sunitinib, some additional targets are not listed.

As used herein, the term ‘antimetabolite” refers to drug compounds thatinhibit the use of a metabolite and thus reduce, prevent or inhibit thegrowth of rapidly dividing cells. For example, antimetabolites of thepresent disclosure may inhibit DNA duplication via different mechanismsresulting in the reduction, prevention or inhibition of cell division.Exemplary antimetabolites for use in the methods described hereininclude, for example, purine and pyramiding analogs such as5-Fluorouracil (5-FU), antibiotics such as Mitomycin-C(MMC), andanti-folate compounds such as Methotrexate. Exemplary antimetabolitesfor use in the methods described herein include, for example, MitomycinC, 5-Fluorouracil, Floxuridine, Cytarabine, 6-Azauracil, Azathioprine,Methotrexate, Mycophenolate Mofetil, and Thiotepa.

Mitomycin-C(MMC) is an example of an antimetabolie as described herein.MMC is an antibiotic and antineoplastic agent, which undergoes reductiveactivation to become a potent alkylating agent. Under hypoxicconditions, it interferes with DNA replication by cross-linking DNA,usually at the N2 position of guanine; as such it is most effective incells that are actively dividing. Under aerobic conditions, it generatestoxic oxygen radicals capable of nonspecific interference with RNA andprotein synthesis. It has been used intravenously as an antineoplasticagent against tumors of the gastrointestinal tract, pancreas, lung, andbreast, among others. It has also been used in an intravascularapplication for bladder cancer.

5-FU is an example of an antimetabolite as described herein. 5-FU is afluorinated pyrimidine and its primary antimetabolic effect is believedto be the inhibition of thymidylate synthetase, which leads to a lack ofintracellular thymidine for DNA production. Additional effects of 5-FUare attributed to inhibition of other enzymes or the incorporation ofits metabolites into RNA.

Multikinase inhibitors and antimetabolites are well known to thosehaving ordinary skill in the art and are commonly used for treatingcancers.

The compositions and methods described herein are useful for treatingpatients at an early stage of pterygium or pinguecula orpseudopterygium, where patients experience ocular discomfort, hyperemia,irritation, blurred vision, foreign body sensation and pain, thetreatment goal is to reduce hyperemia and symptoms. For example, thedisclosure provides compositions and methods of treatment usingnintedanib, a multikinase inhibitor, in a suitable ocular dosage form toreduce hyperemia and other symptoms.

The compositions and methods described herein are also useful fortreating patients at the late stage of pterygium, where thefibrovascular growth extends from conjunctiva across limbus to centralcornea to encroach the visual axis, bare sclera pterygium excision withconjunctival autograft transplantation or with amniotic membranetransplantation would be the procedure of choice for treatment. Althoughthe risk of recurrence with the advancement of surgical techniques andadjunctive therapies has decreased significantly, recurrences continueto be a significant problem for surgeons and patients. To preventpterygium recurrence, the disclosure provides compositions and methodsof treatment using nintedanib in a suitable ocular dosage form to reducepterygium recurrence.

The compositions and methods described herein are also useful fortreating hyperemia and reducing symptoms associated therewith, as shownin the rabbit suture model study provided in Example 1. In this example,nintedanib had excellent efficacy in inhibiting suture-inducedneovascularization in cornea. Table 2 below shows that the percentchange of neovascular area is substantially reduced in the eyes treatedwith nintedanib comparing to the vehicle group. The efficacy ofnintedanib is dependent on dose concentration and dose frequencyregimen. Interestingly, nintedanib showed a clear trend of superiorityto sunitinib in reducing neovascular area. While the two kinaseinhibitors have substantial target overlaps, distinct efficacies werenoted in this rabbit model. Another advantage of nintedanib is that itinhibits a smaller number of targets than sunitinib, allowing for bettersafety margins and higher doses. In fact, as shown in Example 1, apotential toxicity of abnormal lens with incomplete lenticular opacitywas observed in one rabbit during the dosing period for sunitinib groupwhile none was observed for nintedanib groups. In addition, in an invivo corneal suture rabbit model study where rabbits were placed suturesin the cornea and dosed with sunitinib for 7 days, an anterior chambercellular reaction was observed on day 1 (Perez-Santonja J J et al, Am JOphthalmol. 2010; 150(4): 519-528). Iris surface yellowish staining,which represents sunitinib deposits on the iris surface was observedduring the whole dosing period. Sunitinib settles on the inferiorquadrant of the iris, starting at the pupil rim and spreads to someextent between the pupil and the anterior chamber angle, which couldpotentially lead to toxic effects in a long term. Furthermore,significant toxicity of sunitinib was seen at concentration of >3.3μg/mL after 24 hours of incubation with human corneal epithelial cell(Bayyoud T et al., Current Eye Research, 39(2): 149-154, 2014).

TABLE 2 Neovascular Area Mean Percent Change over Day 7 Baseline (− signindicates decrease) 0.05% 0.2% 0.2% 0.05% 0.05% sunitinib nintedanibnintedanib nintedanib nintedanib Vehicle TID BID TID BID TID TID Day 1010.80 12.09 -16.84 64.08 1.99 199.68 (after 2 days of treatment) P valuevs 0.96 0.247 0.090 0.783 0.003 sunitinib Day 12 49.72 37.15 −13.8045.56 −27.87 189.01 (after 4 days of treatment) P value vs 0.67 0.0740.917 0.016 0.079 sunitinib Day 14 98.38 73.51 −1.51 99.48 32.66 349.43(after 6 days of treatment) P value vs 0.54 0.009 0.984 0.093 0.057sunitinib

Nintedanib and sunitinib both inhibit the key VEGFR and PDGFR familieswith a few non-overlapping targets (see Table 1). But the unique set ofkinase targets of nintedanib seems to make it more effective and safethan sunitinib, indicating that nintedanib may be one of the mostpowerful multikinase inhibitors for reducing corneal neovascularization.The unique profile for the inhibition of the following intracellularand/or cell surface protein kinases at the maximum in vitro IC50 arespecified as VEGFR (1, 2, 3) (IC50<50 nM), PDGFR (α, β) (IC50<100 nM),FGFR (1, 2, 3) (IC50<150 nM), FGFR4 (IC50<1000 nM), FLT3 (IC50<50 nM),Lck (IC50<50 nM), Lyn (IC50<200 nM), and Src (IC50<200 nM). Threetargets of FGFR4, Lyn and Src, are not inhibited by sunitinib or othercommon kinases inhibitors and these may differentiate nintedanib fromsunitinib and others. In addition, the nintedanib's potencies on FGFR1-3are substantially higher than that of sunitinib that may also contributeto the superior efficacy of nintedanib in the cornea suture rabbitmodel.

The compositions and methods described herein are also useful fortreating patients at a mid-stage of pterygium, where fibrovasculargrowth extends from conjunctiva to limbus and cornea. At the mid stageof pterygium, the goal is to stabilize pterygium progression to delay orto avoid surgery for removing pterygium or even to induce pterygiumregression from visual axis/central cornea. To achieve this goal, thedisclosure provides compositions and methods of treatment using amultikinase inhibitor, an antimetabolite, or a combination of both in asuitable ocular dosage form.

An example of the compositions and methods for the treatment of anaffected eye using a multikinase inhibitor to stabilize pterygium and toinduce regression of pterygium are provided in Example 2 below, wherethe effect of such compositions on human pterygium cell growth on thecornea of immune deficient mice are shown. In this study, nintedanib andsunitinib prevented the growth of human pterygium on mouse cornea andnintedanib significantly reduced the size of pterygium. As shown inTable 3, provided below, the pterygium cells grew throughout thetreatment period up to day 17, while in the groups treated withnintedanib, sunitinib, MMC or the combination of nintedanib and MMC,pterygium cells either didn't grow or regressed in the case ofnintedanib. Accordingly, the inventors' novel insights from the mousemodel indicated that it is possible to use a multikinase inhibitor, suchas nintedanib or sunitinib, to stop pterygium growth or even to induceregression of pterygium tissue. As an example, the target kinaseprofiles of a multikinase inhibitors for used in the compositions andmethods described herein can target the following kinases at thespecified in vitro IC₅₀: VEGFR (1, 2, 3) (IC₅₀<200 nM), PDGFR (α, β)(IC₅₀<200 nM), FGFR (1, 2, 3) (IC₅₀<1 μM).

TABLE 3 Pterygium Lesion as Percentage of Cornea area (Day 7 isbaseline) Day 7 Day 10 Day 14 Day 17 % Change Saline Drug Saline DrugSaline Drug Saline Drug Vehicle 15.4 16.2 20.9 18.3 23.6 24.3 28.3 25.40.2% nintedanib 17.2 34.0 20.1 27.3 25.9* 26.5* 30.1** 25.9* 0.002% MMC17.0 30.9 24.8* 27.5 26.1* 26.8 29.9* 24.0 0.05% sunitinib 13.7 23.315.9 21.3 20.6* 19.1 24.8* 17.6 0.2% nintedanib + 16.8 22.0 23.9 27.828.5* 26.4 32.5* 30.6 0.002% MMC TTEST vs day 7: P < 0.05, *; P < 0.01,**; P < 0.001, ***

The compositions and methods described herein are also useful fortreating patients using an antimetabolite inhibitor of epithelial celland fibroblast proliferation to stabilize pterygium and to induceregression of pterygium (see Example 2). As shown in Table 3 above,mitomycin C (MMC) was able to prevent the growth of human pterygia cellsand showed a trend of reducing the size of the pterygia tissue oncornea.

Given the multifactorial nature of pterygium, treatments by acombination of drugs may be necessary to achieve the optimal effects. Asshown in Table 3, the pterygium cells on cornea treated with thecombination of nintedanib and MMC didn't show significant growth whilethe saline control grew significantly.

Formulations and Dosing Regimen

The methods described herein include the manufacture and use ofpharmaceutical compositions, which include compounds identified by amethod described herein as active ingredients. Also included are thepharmaceutical compositions themselves.

Pharmaceutical compositions typically include pharmaceuticallyacceptable excipients. As used herein the language “pharmaceuticallyacceptable excipient” or “pharmaceutically acceptable carrier” includessaline, solvents, dispersion media, coatings, antibacterial andantifungal agents, isotonic and absorption delaying agents, and thelike, compatible with pharmaceutical administration.

Methods of formulating suitable pharmaceutical compositions are known inthe art, see, e.g., Remington: The Science and Practice of Pharmacy,21st ed., 2005; and the books in the series Drugs and the PharmaceuticalSciences: a Series of Textbooks and Monographs (Dekker, NY). Forexample, solutions, suspensions or emulsions used for ophthalmicapplication can include the following components: a sterile diluent suchas water for injection, saline solution, fixed oils, polyethyleneglycols, glycerin, propylene glycol or other synthetic solvents;antibacterial agents; antioxidants; chelating agents; buffers such asacetates, citrates or phosphates and agents for the adjustment oftonicity such as sodium chloride or dextrose. pH can be adjusted withacids or bases, such as hydrochloric acid or sodium hydroxide.

Pharmaceutical compositions suitable for injectable use can includesterile aqueous solutions (where water soluble) or dispersions andsterile powders for the extemporaneous preparation of sterile injectablesolutions or dispersion. It should be stable under the conditions ofmanufacture and storage and must be preserved against the contaminatingaction of microorganisms such as bacteria and fungi. The carrier can bea solvent or dispersion medium containing, for example, water, ethanol,polyol (for example, glycerol, propylene glycol, and liquidpolyetheylene glycol, and the like), and suitable mixtures thereof. Theproper fluidity can be maintained, for example, by the use of a coatingsuch as lecithin, by the maintenance of the required particle size inthe case of dispersion and by the use of surfactants. Prevention of theaction of microorganisms can be achieved by various antibacterial andantifungal agents, for example, parabens, chlorobutanol, phenol,ascorbic acid, thimerosal, and the like. In many cases, it will bepreferable to include isotonic agents, for example, sugars, polyalcoholssuch as mannitol, sorbitol, and sodium chloride in the composition.Prolonged absorption of the injectable compositions can be brought aboutby including in the composition an agent that delays absorption, forexample, aluminum monostearate and gelatin.

Sterile injectable solutions can be prepared by incorporating the activecompound in the required amount in an appropriate solvent with one or acombination of ingredients enumerated above, as required, followed byfiltered sterilization. Generally, dispersions are prepared byincorporating the active compound into a sterile vehicle, which containsa basic dispersion medium and the required other ingredients from thoseenumerated above. In the case of sterile powders for the preparation ofsterile injectable solutions, the preferred methods of preparation arevacuum drying and freeze-drying, which yield a powder of the activeingredient plus any additional desired ingredient from a previouslysterile-filtered solution thereof.

In one embodiment, the therapeutic compounds are prepared with carriersthat will protect the therapeutic compounds against rapid eliminationfrom the body, such as a controlled release formulation, includingimplants and microencapsulated delivery systems. Biodegradable,biocompatible polymers can be used, such as ethylene vinyl acetate,polyanhydrides, polyglycolic acid, collagen, polyorthoesters, andpolylactic acid. Such formulations can be prepared using standardtechniques, or obtained commercially.

The pharmaceutical compositions can be included in a container, pack, ordispenser together with instructions for administration.

Compositions and formulations including a multikinase inhibitor, anantimetabolite, or a multikinase inhibitor in combination with anantimetabolite, as described herein, can be administered topically or asan injection of semi-solid formulation or solid implant, or by any othersuitable methods known in the art. While it is possible to use an agentdisclosed herein for therapy as is, it may be preferable to administerthe agent as a pharmaceutical formulation, e.g., in admixture with asuitable pharmaceutical excipient, diluent, or carrier selected withregard to the intended route of administration and standardpharmaceutical practice. Pharmaceutical formulations include at leastone active compound, in association with a pharmaceutically acceptableexcipient, diluent, and/or carrier.

Administration of a composition or formulation can be once a day, twicea day, three times a day, four times a day or more often. Frequency maybe decreased during a treatment maintenance phase of the treatment,e.g., once every second or third day instead of every day or twice aday. The dose and the administration frequency can be adjusted based onthe judgment of the treating physician, for example taking into accountthe clinical signs, pathological signs and clinical and subclinicalsymptoms of a disease of the conditions treated with the presentmethods, as well as the patient's clinical history.

It will be appreciated that the amount of an agent disclosed hereinrequired for use in treatment will vary with the route ofadministration, the nature of the condition for which treatment isrequired, and the age, body weight and condition of the patient, andwill be ultimately at the discretion of the attendant physician.Compositions will typically contain an effective amount of the activeagent(s), alone or in combination. Preliminary doses can be determinedaccording to animal tests, and the scaling of dosages for humanadministration can be performed according to art-accepted practices.

Length of treatment, i.e., number of days, will be readily determined bya physician treating the subject; however, the number of days oftreatment may range from about 1 day to about 365 days. As provided bythe present methods, the efficacy of treatment can be monitored duringthe course of treatment to determine whether the treatment has beensuccessful, or whether additional (or modified) treatment is necessary.

Dosage, toxicity and therapeutic efficacy of the therapeutic compoundscan be determined by standard pharmaceutical procedures in cell culturesor experimental animals, e.g., for determining the LD50 (the dose lethalto 50% of the population) and the ED50 (the dose therapeuticallyeffective in 50% of the population). Dosage s dosage forms for themultikinase inhibitor, the antimetabolite and their individual dosestrength in the combination therapy can be readily determined by theordinarily skilled artisan, and can e.g., be obtained in animal modelsand in clinical studies reported in the literatures, for determiningdosage, safety and efficacy according to standard methods known in theart. The exact formulation, route of administration and dosage can bechosen by the individual physician in view of the patient's condition.

Dosage strengths of the multikinase inhibitor include, for example,about 0.001 to about 100.0 mg, about 0.01 to about 90 mg, about 0.1 mgto about 75 mg, about 0.25 to about 50 mg, about 0.5 to about 25 mg,about 0.75 to about 20 mg, about 1.0 to about 15 mg, about 1.25 to about10 mg, about 1.5 to about 5.0 mg, about 1.75 to about 2.5 mg, e.g.,0.001 mg, 0.01 mg, 0.1 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1.0 mg, 1.25 mg,1.5 mg, 1.75 mg, 2.0 mg, 2.5 mg, 5.0 mg 10.0 mg 15.0, mg 25.0 mg, 30.0mg, 40.0 mg, 50.0 mg, 60.0 mg, 75.0 mg, or 100.0 mg of the multikinaseinhibitor. For example, dosage strengths of nintedanib include, forexample, 0.1 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1.0 mg, 1.25 mg, 1.5 mg, 1.75mg, 2.0 mg, 2.5 mg, 5.0 mg 10.0 mg 15.0, mg 25.0 mg, 30.0 mg, 40.0 mg,50.0 mg, 60.0 mg, 75.0 mg, or 100.0 mg of nintedanib.

Compositions for use in the present methods may include a multikinaseinhibitor at a concentration of 0.001% to 10% by weight or by volume thetotal amount of composition. For example, an aqueous compositioncomprises 0.001%, 0.01%, 0.1%, 0.5%, 1.0%, 1.5%, 2.0%, 5.0% or up to 10%nintedanib.

Dosage strengths of the antimetabolite include, for example, about 0.001to about 100.0 mg, about 0.01 to about 90 mg, about 0.1 mg to about 75mg, about 0.25 to about 50.0 mg, about 0.5 to about 25 mg, about 0.75 toabout 20 mg, about 1.0 to about 15 mg, about 1.25 to about 10 mg, about1.5 to about 5.0 mg, about 1.75 to about 2.5 mg, e.g., 0.001 mg, 0.01mg, 0.1 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1.0 mg, 1.25 mg, 1.5 mg, 1.75 mg,2.0 mg, 2.5 mg, 5.0 mg 10.0 mg 15.0, mg 25.0 mg, 30.0 mg, 40.0 mg, 50.0mg, 60.0 mg, 75.0 mg, or 100.0 mg of the antimetabolite. For example,dosage strengths of MMC include, for example. 0.1 mg, 0.25 mg, 0.5 mg,0.75 mg, 1.0 mg, 1.25 mg, 1.5 mg, 1.75 mg, 2.0 mg, 2.5 mg, 5.0 mg 10.0mg 15.0, mg 25.0 mg, 30.0 mg, 40.0 mg, 50.0 mg, 60.0 mg, 75.0 mg, or100.0 mg of MMC.

Compositions for use in the present methods may include anantimetabolite at a concentration of 0.001% to 10% by weight or byvolume the total amount of composition. For example, an aqueouscomposition comprises 0.001%, 0.01%, 0.1%, 0.5%, 1.0%, 1.5%, 2.0%, 5.0%or up to 10% MMC.

As will be familiar to those skilled in the art, administration to theeye of an aqueous solution may be in the form of “drop” or number ofdrops (e.g. of a multikinase inhibitor solution, an antimetabolitesolution or combination thereof) from a dropper or pipette or otherdedicated sterile device. Such drops will typically be up to 50microliters in volume, but maybe smaller e.g. less than 10 microliters.

EXAMPLES

The invention is further described in the following examples, which donot limit the scope of the invention described in the claims.

Example 1: Rabbit Cornea Suture Model of Neovascularization andHyperemia

The rabbit cornea suture model was established to assess drug effects oncornea neovascularization (Ko et al. Cornea. 2013; 32(5): 689-695;Pérez-Santonja et al. Am J Ophthalmol. 2010; 150(4):519-528). Nintedanibwas studied in this model for its anti-neovascularization activity.

Topical Ocular Formulations

Topical compositions comprising 0.2% or 0.05% nintedanib in 10%2-hydroxypropyl beta cyclodextrin in phosphate buffer solution, pH 7.4were prepared. In addition, a composition comprising 0.05% sunitinib wasprepared in the same vehicle to serve as positive control.

Animals and Treatment Procedure

Thirty six female Zealand White rabbits were used to perform the study.Briefly, five sutures were placed in the upper cornea of the right eyeof each animal on Day 1 to induce neovascularization. The animals weretreated in both eyes as described in Table 4.

TABLE 4 Dosing Dosing Number of Period Group Treatment Frequency FemalesDays 1 to 1 Saline Once daily 6 females 7 2 Saline Once daily 6 females3 Saline Once daily 6 females 4 Saline Once daily 6 females 5 SalineOnce daily 6 females 6 Saline Once daily 6 females Days 8 to 1 0.05%sunitinib solution TID 6 females 15 2 0.2% nintedanib solution BID 6females 3 0.2% nintedanib solution TID 6 females 4 0.05% nintedanibsolution BID 6 females 5 0.05% nintedanib solution TID 6 females 6Saline (OD), Vehicle (OS) TID 6 females BID: Twice per day(approximately 10 to 12 hours apart). TID: Three times per day(approximately 6 to 8 hours apart). OD = right eye. OS = left eye. Botheyes were dosed, the dose volume was approximately 40 μL/eye. Note: Thefirst dose of saline on Day 1 was done 4 hours post suture placement.

During the study, the animals were closely observed for various ocularindications as well as general physical conditions including bodyweight. Ocular images were taken on days 7, 10, 12, 14, 21, 28 foranalysis.

Data Analysis

NIH ImageJ® software was used to analyze the ocular images. Each imagewas opened in ImageJ®, the scale was calibrated using the ruler in thephotograph and the neovascularized area on the cornea near the suturewas selected by the selection tool. The area in mm² was calculated bymeasurement tool in the software, recorded in excel and the image wascaptured and saved. Two-tailed t-TEST was used to determine whetherpairs of groups are significantly different. The results were plotted ashistograms of average with standard deviation for easy comparison.

Results and Discussions

The results of this study are summarized below in FIGS. 1A and 1B andTable 5. The results demonstrate that nintedanib had a marked inhibitoryeffect on suture-induced neovascularization in the rabbit cornea. Higherdose of 0.2% nintedanib showed improved efficacy compared with 0.05%nintedanib, while more frequent dosing regimen of TID dosing showedimproved efficacy compared with BID dosing. Surprisingly, nintedanibshowed a clear trend of superiority to the positive control sunitinib inreducing neovascular area in this model.

In the rabbit suture model, sunitinib has previously been shown toinhibit vascularization more effectively than bevacizumab, an anti-VEGFantibody (Ko et al. Cornea. 2013; 32(5): 689-695; Pérez-Santonja et al.Am J Ophthalmol. 2010; 150(4):519-528). Their observation suggested thatsmall molecule kinase inhibitors targeting multiplereceptor-tyrosine-kinase pathways may have advantages over antibodydrugs targeting a very selective pathway. The present results showedthat nintedanib also inhibited neovascularization very effectively inthe suture model. Quite unexpectedly, the inventors found that kinaseinhibitors with substantial kinase target overlaps can still havedifferent efficacies. Although nintedanib and sunitinib both inhibit thekey VEGFR family, they have several non-overlapping targets. As shown inTable 1, the target profile of nintedanib is different from that ofsunitinib as well as several other MKI's considered very similar in theresearch community. The special set of kinase targets of nintedanibseems offer at least two surprising advantages: 1) it makes nintedanib ahighly effective inhibitor of neovascularization, more so thansunitinib, as demonstrated in the rabbit suture model; 2) it targetsfewer kinases than sunitinib, allowing for better safety margins andhigher doses. Accordingly, it is understood that nintedanib hasdemonstrated an improved efficacy and a better safety profile ascompared with sunitinib.

TABLE 5 Neovascular Area in mm² with TTEST P Value Against Sunitinibcontrol 0.05% 0.2% 0.2% 0.05% 0.05% sunitinib nintedanib nintedanibnintedanib nintedanib Veh TID BID TID BID TID TID Day 10 3.58 3.32 2.485.97 3.23 10.09 (after 2 days of treatment) P value vs 0.819 0.283 0.040.780 0.004 sunitinib Day 12 4.62 4.15 2.56 5.03 2.14 8.91 (after 4 daysof treatment P value vs 0.697 0.153 0.749 0.055 0.03 sunitinib Day 145.96 5.44 2.88 7.20 4.01 13.16 (after 6 days of treatment) P value vs0.750 0.024 0.532 0.159 0.002 sunitinib

The rationale of our claim is supported by previous findings in cancerresearch, a field where MKIs are used extensively. For cancer, some MKIswith substantial overlapping targets could still have very differentefficacy in patients. For example, many small-molecule MKIs withoverlapping targets were tested in non-small-cell-lung-cancer (NSCLC)patients, but interestingly, only nintedanib showed efficacy and isapproved for combination therapy with other drugs (Hall R D et al.Transl Lung Cancer Res. 2015; 4(5), 515-23). Observations like thisindicated that the target profile of a kinase inhibitor can dramaticallyaffect efficacy in certain indications.

Our novel insights are summarized as following: First, in general, smallmolecule MKIs with certain target profiles are better than antibodydrugs for treating abnormal cornea neovascularization. Although this washinted by previous studies, it was based on a single pair of comparisonbetween bevacizumab and sunitinib. Now, our study of nintedanib addedmuch more weight to this theory. Second, our novel idea is that each MKIhas its unique target profile and not all MKIs will be equally safe andefficacious in treating pterygium symptoms. Without being bound bytheory, we believe nintedanib offers a unique profile that will provideone of the most effective and safe treatments for pterygium.

In summary, the unique target profile of nintedanib can make it a moreeffective and safer drug for treating pterygium. Nintedanib inhibitsFGFR1-3 more effectively than sunitinib. It also inhibits FGFR4, Lyn,Src that are not targets of sunitinib (see Table 1 in the backgroundsection). In addition, nintedanib is expected to have better safetyprofiles than sunitinib because sunitinib is known to hit more kinasesthan compounds in the same class (Kumar et al. Br J Cancer. 2009;101(10):1717-23) and it inhibits some additional kinases not listedTable 1. Some of these, such as the CaMK family, are important fornormal cellular functions and their inhibition could have safety issues.

Example 2: The Human Pterygium Mouse Model

The human pterygium mouse model was described to assess human pterygiumgrowth on the cornea of immune deficient mouse (Lee et al., Graefes ArchClin Exp Ophthalmol. 2014; 252(4):609-18). The present studyinvestigated the effects of several drugs' effect on pterygium growth.The drugs are nintedanib, sunitinib and mitomycin C.

Topical Ocular Formulations

The articles tested were prepared in 10% 2-hydroxypropyl betacyclodextrin in phosphate buffer solution, pH 7.4. The detailedinformation of the formulation is disclosed in a section below.

Animals

Seven weeks old male athymic nude mice were adapted under pathogen-freeconditions in enclosed filter-topped cages.

Human Pterygium Primary Cell Culture

Human pterygium epithelial cells (hPECs) were isolated and cultured fromspecimen collected after surgical excision. All participants providedwritten informed consent after having received a comprehensiveexplanation of the study. Fresh pterygium specimens were cultured onsurfaces coated with collagen (rat tail collagen type I) for three daysin DMEM/F12 medium supplemented with 10% bovine calf serum, 0.5%dimethyl sulfoxide, and 1% antibiotic/anti-mycotic, during which timethe cells migrated from the explant. Then, the explant was removed, andthe medium was changed to keratinocyte-serum free medium with 5% BCS,and 1% antibiotic/anti-mycotic to further promote epithelial cellgrowth.

Induction of Human Pterygium

Mice were anesthetized by i.p. injection of ketamine (30 mg/kg) andrumpun (2.5 mg/kg) for subconjunctival injection. Pterygium in mouse wasinduced by injecting 1×10⁴ hPECs in the nasal subconjunctival space ofboth eyes on day 0. After 7 days, the mice induced with hPEC weresubjected to test.

Treatments

Animals were treated as following:

-   -   Group 1: vehicle right eye and saline left eye;    -   Group 2: 0.2% nintedanib right eye and saline left eye;    -   Group 3: 0.002% mitomycin right eye and saline left eye;    -   Group 4: 0.05% sunitinib right eye and saline left eye;    -   Group 5: 0.2% nintedanib and 0.002% mitomycin mixture right eye        and saline left eye.        Animals were treated by nasal subconjunctival injection on day        7, 10, and 14 and by topical eye drop dosing QID on day 8, 9,        11, 12, 13, 15, and 16. Before each injection and also on day        17, the eyes were observed and captured by using stereo        microscope.        Clinical ObservationAPP

Mice were observed daily for clinical signs of toxicity duringexperiment. The eyes were observed and captured before injection and atday 17. All findings including illness, diagnoses, and therapy wererecorded. The weights of mice were measured at day 0, 7, day 11, day 15and day 17.

Corneal Pterygium Analysis

Image analysis of the photograph was performed using ImageJ® to measurethe lesion size at day 0, 7, 10, 14 and 17. These data were calculatedas the ratio of the pterygium to the entire cornea.

Corneal Neovascularization Analysis

The clinical features of the eyes of all mice were evaluated. The extentof corneal neovascularization (NV) was scored from 0 through 3, where0=no NV, 1=NV confined to the corneal periphery, 2=NV extending up tothe pupil margin, and 3=NV extending beyond the pupil margin into thecentral cornea.

Statistical Analysis

Data were analyzed by SPSS version 18.0 for Windows (SPSS, Chicago,Ill.) and are expressed as the mean±standard deviation.

Results and Discussions

The results are shown in FIGS. 2A-B, 3A-B, 4A-B and 5A-B, and alsosummarized in Table 4 above. In the human pterygium mouse model, 0.2%nintedanib treatment led to a reduction of the pterygium area on day 14and day 17 in comparison to the baseline level on day 7 (FIGS. 2A and2B). In contrast, the control saline treated eyes showed increases ofpterygium areas on day 14 and day 17. Nintedanib also reducedneovascularization score on the cornea during the treatments with thelevel on day 17 showing a significant difference from the baseline onday 7 (FIGS. 2A and 2B) while the control eyes showed a smallnon-statistically significant increase of neovascularization (FIGS. 2Aand 2B). In this model, 0.002% mitomycin and 0.05% sunitinib also showeda trend of reduction in pterygium areas but didn't reach statisticalsignificance at any of the time points (FIGS. 3A-3B, 4A-4B). Incontrast, the control saline treated eyes showed increases of pterygiumareas on nearly all the time points and increases are nearly linear overtime. Mitomycin and sunitinib also reduced neovascularization score,with significant reductions on day 17 for mitomycin and on day 14 andday 17 for sunitinib (FIGS. 3A-3B, 4A-4B). Again, the control eyesdidn't show significant change of neovascularization during thetreatment. In the eyes treated with a combination of nintedanib andmitomycin, the pterygium areas didn't increase while the saline controlincreased significantly (FIGS. 5A-5B). The neovascularization scoredidn't show significant change in this group of animal.

Example 3: Formulations

Nintedanib Ophthalmic Solution

The drug product is an isotonic ophthalmic solution prepared in2-hydroxypropyl beta cyclodextrin or other similar cyclodextrins, andbuffer solution, pH range from 5.5 to 8.0. Other viscosity, lubricant,preservative agents might be added to enhance functionality of theformulation. The compositions of the ophthalmic solution are disclosedin Table 6.

TABLE 6 Nintedanib Ophthalmic Solution Concentration Range IngredientsFunctions (% w/v) CBT-001 (Nintedanib free Active Pharmaceutical0.001-10   base) Ingredient Sodium Viscosity Agent/dry eye 0-1carboxymethylcellulose relief Pemulen TR Viscosity Agent  0-0.2Polyvinyl alcohol Viscosity/Lubrication  0-1.5 Agent HypromelloseLubricant/dry eye relief 0-1 Carbomers Lubricant/dry eye relief  0-0.5Carmellose sodium Lubricant/dry eye relief 0-1 Sodium hyaluronateLubricant/dry eye relief  0-1.5 Polyethylene glycol 400 Lubricant/dryeye relief  0-0.4 Propylene glycol Lubricant/dry eye relief  0-0.62-hydroxypropyl beta Solubilizer  0-10 cyclodextrin Sulfobutyl-beta-Solubilizer  0-10 cyclodextrin Randomly methylated beta- Solubilizer 0-5cyclodextrin α-cyclodextrin Solubilizer 0-4 β-cyclodextrin Solubilizer0-1 γ-cyclodextrin Solubilizer 0-1 Poloxamer 188, or 237, orSolubilizer/lubricant 0-5 407 Polysorbate 80 Solubilizer/lubricant/ 0-1surfactant Edetate disodium Chelating Agent/   0-0.01 PreservativeBenzalkonium chloride Preservative   0-0.02 Sodium phosphate BufferAgent   0-0.43 monobasic monohydrate Sodium phosphate dibasic BufferAgent  0-0.8 heptahydrate Boric acid Buffer Agent  0-0.6 Sodium borate,Buffer Agent    0-0.045 decahydrate Citric acid, monohydrate BufferAgent/preservative   0-0.13 Sodium citrate, dihydrate BufferAgent/preservative   0-0.45 Glycerin Tonicity Agent  0-2.2 Sodiumchloride Tonicity Agent   0-0.83 1N Sodium hydroxide pH Adjustment pH5.5-8.0 1N Hydrochloric acid Water for injection Vehicle Q.S. to 100Nintedanib Ophthalmic Suspension

The drug product is an isotonic ophthalmic suspension prepared incarboxymethylcellulose sodium and buffer solution, pH range from 5.5 to8.0. The drug particle sizes are reduced to below 40 micron. Otherviscosity, lubricant, solubilizer, and preservative agents might beadded to enhance functionality of the formulation suspension. Thecompositions are disclosed in Table 7.

TABLE 7 Nintedanib Ophthalmic Suspension Concentration Range IngredientsFunctions (% w/v) CBT-001 (Nintedanib free Active Pharmaceutical0.001-10   base) Ingredient Sodium Viscosity Agent/dry eye 0-1carboxymethylcellulose relief Pemulen TR Viscosity Agent  0-0.2Polyvinyl alcohol Viscosity/Lubrication  0-1.5 Agent HypromelloseLubricant/dry eye relief 0-1 Carbomers Lubricant/dry eye relief  0-0.5Carmellose sodium Lubricant/dry eye relief 0-1 Sodium hyaluronateLubricant/dry eye relief  0-1.5 Polyethylene glycol 400 Lubricant/dryeye relief  0-0.4 Propylene glycol Lubricant/dry eye relief  0-0.62-hydroxypropyl beta Solubilizer  0-10 cyclodextrin Sulfobutyl-beta-Solubilizer  0-10 cyclodextrin Randomly methylated beta- Solubilizer 0-5cyclodextrin α-cyclodextrin Solubilizer 0-4 β-cyclodextrin Solubilizer0-1 γ-cyclodextrin Solubilizer 0-1 Poloxamer 188, or 237, orSolubilizer/lubricant 0-5 407 Polysorbate 80 Solubilizer/lubricant/ 0-1surfactant Edetate disodium Chelating Agent/   0-0.01 PreservativeBenzalkonium chloride Preservative   0-0.02 Sodium phosphate BufferAgent   0-0.43 monobasic monohydrate Sodium phosphate dibasic BufferAgent  0-0.8 heptahydrate Boric acid Buffer Agent  0-0.6 Sodium borate,Buffer Agent    0-0.045 decahydrate Citric acid, monohydrate BufferAgent/preservative   0-0.13 Sodium citrate, dihydrate BufferAgent/preservative   0-0.45 Glycerin Tonicity Agent  0-2.2 Sodiumchloride Tonicity Agent   0-0.83 1N Sodium hydroxide pH Adjustment pH5.5-8.0 1N Hydrochloric acid Water for injection Vehicle Q.S. to 100Nintedanib Ophthalmic Emulsion

The drug product is an isotonic ophthalmic emulsion. The drug isdissolved in the mixture oil phase and emulsifier excipients which isthen emulsified and mixed with an aqueous phase with pH range from 5.5to 8.0. Other viscosity, lubricant, solubilizer, and preservative agentsmight be added to enhance functionality of the emulsion formulation. Thecompositions are disclosed in Table 8.

TABLE 8 Nintedanib Ophthalmic Emulsion Concentration IngredientsFunctions (% w/w) CBT-001 (Nintedanib free Active Pharmaceutical0.001-10   base) Ingredient Castor oil Oil solvent   0-1.25Polyoxyl-40-Stearate Emulsifier   0-0.25 Polysorbate 80Solubilizer/Emulsifier/ 0-1 Surfactant Sulfobutyl-β-cyclodextrinSolubilizer 0-5 2-Hydroxypropyl-beta- Solubilizer 0-5 cyclodextrinRandomly methylated beta- Solubilizer 0-5 cyclodextrin α-cyclodextrinSolubilizer 0-4 β-cyclodextrin Solubilizer 0-1 γ-cyclodextrinSolubilizer 0-1 Glycerin Tonicity Agent  0-2.2 Sodium Chloride TonicityAgent   0-0.83 Pemulen TR2 Viscosity Agent  0-0.1 Sodium Viscosity Agent 0-0.5 carboxymethylcellulose Polyvinyl alcohol Viscosity/Lubrication 0-1.5 Agent Hypromellose Lubricant/dry eye relief 0-1 CarbomersLubricant/dry eye relief  0-0.5 Carmellose sodium Lubricant/dry eyerelief 0-1 Sodium hyaluronate Lubricant/dry eye relief  0-1.5Polyethylene glycol 400 Lubricant/dry eye relief  0-0.4 Propylene glycolLubricant/dry eye relief  0-0.6 Poloxamer 188, or 237, orSolubilizer/lubricant 0-5 407 Boric acid Buffer  0-0.6 Sodium borate,Buffer    0-0.045 decahydrate Citric acid, monohydrateBuffer/preservative   0-0.13 Sodium citrate, dihydrateBuffer/preservative   0-0.45 Sodium phosphate, Buffer   0-0.43 monobasicmonohydrate Sodium phosphate dibasic Buffer  0-0.8 heptahydrate 1N & 5NSodium pH Adjustment pH 5.5-8.0 hydroxide 1N Hydrochloric acid Water forinjection Aqueous Vehicle Q.S. 100Nintedanib Sustained Release Semi-Solid Formulation

The drug product is an isotonic sustained release semi-solidformulation. The drug is dissolved and/or suspended in a semi-solidmedium with pH range from 5.5 to 8.0. Other viscosity, lubricant,solubilizer, and preservative agents might be added to enhancefunctionality of the sustained release semi-solid formulation. Thecompositions are disclosed in Table 9.

TABLE 9 Sustained Release Semi-Solid Formulation ConcentrationIngredients Functions (% w/w) CBT-001 (Nintedanib free ActivePharmaceutical 0.001-10     base) Ingredient Xanthan GumViscosity/Thickener 0-10  Hydroxypropyl Viscosity/Thickener 0-10 methylcellulose Sodium hyaluronate Viscosity/Thickener 0-5   Hyaluronicacid Viscosity/Thickener 0-5   Boric acid Buffer 0-0.6  Sodium borate,Buffer  0-0.045 decahydrate Citric acid, monohydrate Buffer/preservative0-0.13 Sodium citrate, dihydrate Buffer/preservative 0-0.45 Sodiumphosphate, Buffer 0-0.43 monobasic monohydrate Sodium phosphate dibasicBuffer 0-0.8  heptahydrate 1N & 5N Sodium pH Adjustment pH 5.5-8.0hydroxide 1N Hydrochloric acid Water for injection Aqueous Vehicle Q.S.100Nintedanib Sustained Release Implants

The drug product is a solid implant. The drug is mixed and blended withone or more polymers. The mixture of drug and polymers is melted at apredetermined temperature and extruded into a filament with apredetermined diameter size. The formulation filament is cut into apredetermined size of segment which can be implanted into oculartissues. The compositions are disclosed in Table 10.

TABLE 10 Sustained Release Implants Concentration Ingredients Functions(% w/w) CBT-001 (Nintedanib free Active Pharmaceutical 0.001-10    base)Ingredient Poly (D,L-Lactide), i.v. Polymer 0-100 0.25-0.35 dL/g Poly(D,L-Lactide- Polymer 0-100 coglycolide) i.v. 0.14-0.22 dL/g Poly(D,L-Lactide), i.v. Polymer 0-100 0.16-0.25 dL/g Polyethylene Glycol3350 Polymer 0-20  Resomer ®RG755S Polymer 0-100 Resomer ®RG753H Polymer0-100Without limitation, an example composition, for use in the methodsaccording to the invention, may be modified from existing ophthalmicallyacceptable compositions.

Other Embodiments

It is to be understood that while the invention has been described inconjunction with the detailed description thereof, the foregoingdescription is intended to illustrate and not limit the scope of theinvention, which is defined by the scope of the appended claims. Otheraspects, advantages, and modifications are within the scope of thefollowing claims.

What is claimed is:
 1. A method for inducing regression of a pterygiumfrom the central cornea of an affected eye without surgically excisingthe pterygium, comprising administering to the affected eye of a subjectin need of such treatment a therapeutically effective amount of amultikinase inhibitor.
 2. The method of claim 1, wherein the multikinaseinhibitor reduces the kinase activity of one or more intracellularand/or cell surface protein kinases selected from EGFR, ErbB2, ErbB3,FGFR1, TrkA, NGFR, VEGFR (1, 2, 3), PDGFR (α, β), TGF-βR (I, II, III),FLT3, c-Kit, RET, CSF-1R in the pterygium.
 3. The method of claim 1,wherein the multikinase inhibitor is selected from the group consistingof Afatinib, Amuvatinib, Axitinib, Cabozantinib, Canertinib, Cediranib,Ceritinib, Crenolanib, Crizotinib, Dabrafenib, Dacomitinib, Dasatinib,Erlotinib, Foretinib, Gefitinib, Golvatinib, Ibrutinib, Icotinib,Idelalisib, Imatinib, Lapatinib, Lenvatinib, Neratinib, Nilotinib,Nintedanib, Palbociclib, Pazopanib, Ponatinib, Quizartinib, Regorafenib,Ruxolitinib, Sorafenib, Sunitinib, Tandutinib, Tivantinib, Tivozanib,Trametinib, Vandetanib, Vatalanib, and Vemurafenib.
 4. The method ofclaim 1, further comprising administering to the affected eye subject inneed of such treatment a therapeutically effective amount of anantimetabolite is selected from the group consisting of Mitomycin C,5-Fluorouracil, and Thiotepa.
 5. The method of claim 1, wherein themultikinase inhibitor is administered to the affected eye in the form ofa topical ocular formulation or an ocular implant.
 6. The method ofclaim 5, wherein the multikinase inhibitor is administered topically tothe affected eye in the form of a topical ocular formulation.
 7. Themethod of claim 1, wherein the multikinase inhibitor is Nintedanib. 8.The method of claim 1, further comprising identifying a patient seekingto avoid or delay pterygium surgery as the subject in need prior toadministering the multikinase inhibitor.
 9. A method for stabilizing apterygium in an affected eye without surgically excising the pterygium,comprising administering to the affected eye of a subject in need ofsuch treatment a therapeutically effective amount of a multikinaseinhibitor.
 10. The method of claim 9, wherein the multikinase inhibitorreduces the activity of one or more intracellular and/or cell surfaceprotein kinases selected from EGFR, ErbB2, ErbB3, FGFR1, TrkA, NGFR,VEGFR (1, 2, 3), PDGFR (α, β), TGF-βR (I, II, III), FLT3, c-Kit, RET,CSF-1R in the pterygium.
 11. The method of claim 9, wherein themultikinase inhibitor is selected from the group consisting of Afatinib,Amuvatinib, Axitinib, Cabozantinib, Canertinib, Cediranib, Ceritinib,Crenolanib, Crizotinib, Dabrafenib, Dacomitinib, Dasatinib, Erlotinib,Foretinib, Gefitinib, Golvatinib, Ibrutinib, Icotinib, Idelalisib,Imatinib, Lapatinib, Lenvatinib, Neratinib, Nilotinib, Nintedanib,Palbociclib, Pazopanib, Ponatinib, Quizartinib, Regorafenib,Ruxolitinib, Sorafenib, Sunitinib, Tandutinib, Tivantinib, Tivozanib,Trametinib, Vandetanib, Vatalanib, and Vemurafenib.
 12. The method ofclaim 9, further comprising administering to the affected eye subject inneed of such treatment a therapeutically effective amount of anantimetabolite selected from the group consisting of Mitomycin C,5-Fluorouracil, and Thiotepa.
 13. The method of claim 9, wherein themultikinase inhibitor is administered to the affected eye in the form ofa topical ocular formulation or an ocular implant.
 14. The method ofclaim 13, wherein the multikinase inhibitor is administered topically tothe affected eye in the form of a topical ocular formulation.
 15. Themethod of claim 9, wherein the multikinase inhibitor is Nintedanib. 16.The method of claim 9, further comprising identifying a patient seekingto avoid or delay pterygium surgery as the subject in need prior toadministering the multikinase inhibitor.
 17. A method for reducing therate of growth of a pterygium in an affected eye without surgicallyexcising the pterygium, comprising administering to an affected eye of asubject in need of such treatment a therapeutically effective amount ofa multikinase inhibitor.
 18. The method of claim 17, wherein themultikinase inhibitor reduces the activity of one or more intracellularand/or cell surface protein kinases selected from EGFR, ErbB2, ErbB3,FGFR1, TrkA, NGFR, VEGFR (1, 2, 3), PDGFR (α, β), TGF-βR (I, II, III),FLT3, c-Kit, RET, CSF-1R in the pterygium.
 19. The method of claim 17,wherein the multikinase inhibitor is selected from the group consistingof Afatinib, Amuvatinib, Axitinib, Cabozantinib, Canertinib, Cediranib,Ceritinib, Crenolanib, Crizotinib, Dabrafenib, Dacomitinib, Dasatinib,Erlotinib, Foretinib, Gefitinib, Golvatinib, Ibrutinib, Icotinib,Idelalisib, Imatinib, Lapatinib, Lenvatinib, Neratinib, Nilotinib,Nintedanib, Palbociclib, Pazopanib, Ponatinib, Quizartinib, Regorafenib,Ruxolitinib, Sorafenib, Sunitinib, Tandutinib, Tivantinib, Tivozanib,Trametinib, Vandetanib, Vatalanib, and Vemurafenib.
 20. The method ofclaim 17, further comprising administering to the affected eye subjectin need of such treatment a therapeutically effective amount of anantimetabolite selected from the group consisting of Mitomycin C,5-Fluorouracil, and Thiotepa.
 21. The method of claim 17, wherein themultikinase inhibitor is administered to the affected eye in the form ofa topical ocular formulation or an ocular implant.
 22. The method ofclaim 21, wherein the multikinase inhibitor is administered topically tothe affected eye in the form of a topical ocular formulation.
 23. Themethod of claim 17, wherein the multikinase inhibitor is Nintedanib. 24.The method of claim 17, further comprising identifying a patient seekingto avoid or delay pterygium surgery as the subject in need prior toadministering the multikinase inhibitor.